Monday, November 18, 2013

Since Mikko was a baby, we've been dealing with drama surrounding elimination. When he was a toddler, this morphed into an unwillingness to defecate.

This is a post I've been debating whether or not to publish, and one I might take down at some point as Mikko gets older and needs more privacy. For now, I've decided to post it, because: (a) You're not alone if you're dealing with this same issue, and (b) there's nothing shameful about toileting issues, no matter what age. It can be really worth it to talk openly about struggles with going.

There are many reasons a child might have resistance to eliminating — some physical and some psychological. It's appropriate to rule out physical reasons first, and I am not a doctor, so check with your own medical providers for advice on any physical obstacles. We ruled out any sort of issues with physical structure or internal disorders with Mikko, so we were cleared to proceed with examining other causes.

The most common cause suggested for trouble pooping was not what Mikko's problem was. To whit, he does not suffer from constipation. Any time we brought up his hesitance to poop, we got advice on constipation — whether it was with his pediatrician or other well-meaning parents. But Mikko's stools are soft and well-formed and come along with regularity. Constipation was not his problem.1 So what was?
Based on my own research and our growing knowledge of our child, we've come to the conclusion that Mikko's resistance to pooping is sensory-based. That is to say, he hates the sensation of pooping.

He has to poop; he feels the need. He chooses not to.

What he does, then, is known as stool withholding or bowel withholding.

(It can also be a type of encopresis, which is a fancy name for underpants soiling.)

I thought we were alone in this until I started looking online, and lo and behold, there are many children and parents going through this same struggle! Many of the children have Sensory Processing Disorder, which isn't something Mikko's been diagnosed with, but I can see many similarities in his quirks and the listed symptoms. Since I now know pooping resistance is more common that we thought, and yet it's not often talked about, I really wanted to write this post and share a little about the whys, hows, and what-to-dos concerning a sensory resistance to pooping.

Our poop-withholding story

Even when Mikko was a newborn, each pee or poop was met with screaming and crying. We did part-time elimination communication with cloth diaper backup, and we simply got used to trying to react as quickly as possible to his needs to eliminate or be changed. He would get upset when he had to go, upset while he was going, and upset afterward if he was wet or messy.

Since he was our firstborn, we didn't know what to make of this. We knew he was a high-needs baby, but we figured things would get better — and they did, sort of. He went on a prolonged potty strike first, for almost a year, but then just before turning 2, he was potty independent, and we figured all the potty drama was behind us. Um…no.

At some point in his preschooler days, he went from a kid who willingly used the toilet for everything to one who withheld his poop for as long as he could. I honestly can't even remember at what age this started — only that he grew more and more skilled at holding it in.

The longest stretch was two weeks. As in, two weeks in which he had to poop but refused. Likely it was longer than that between poops, but it was two weeks from the time we noticed he needed to before he finally gave in. He would sit on the couch or other comfortable seats whenever possible, and he would clench. He would clench as if his life depended on it.

It was very common for him to go a week or more between pooping, with two days of cheery nonchalance, and then four to eight days of sedentary clenching. When Mikko is his I-have-to-poop-but-won't phases, he sweats and is flushed. He seeks out the most padded places to sit everywhere we go. He tries not to have to walk anywhere. He refuses to play except sitting on the couch or bed. He doesn't want to eat or drink to add to the buildup. In short, it interferes with his life — the life of a normal little kid.

Plus, the smell. And the mess. When I say he holds it in, he tries. Good heaven, how he tries. But it leaks out, and his underwear is full of streaks and, as time goes on, clumps. His pants smell like a squirrel died in them. It makes cosleeping — and even being near him — hard for us. Sometimes he holds it so long that it turns to diarrhea, and then we have memorable occasions such as the time we were walking to a ball game at the stadium and had to duck into a Starbucks to clean up the brown liquid that was running down his legs and filling up his Crocs. I in turn had to dash to the car and fish his swim trunks out to serve as emergency backup undies.

Sam and I got worried. We got anxious about the health concerns of holding in poop for that long. We got irritated that Mikko wouldn't just — be — normal. What kid holds in his poop in such a dedicated way for so dang long?

Well: Yes, what makes some kids do this?

Why some children won't poop

For some kids, pooping is painful. Maybe they are constipated (see above and the footnote); maybe they have some sort of bowel obstruction or irritable bowel syndrome. Maybe they have undiagnosed food sensitivities that make passing poop like passing fire.

This didn't seem to be the case with Mikko, and when we tried to talk with him, it was like talking with a … well, with a preschooler. They can't always articulate these things, you know? The best we could determine was that he didn't like how it feels.

In fact, he didn't like it so much, he would rather feel the (for me, far worse) sensation of needing to clench-clench-clench those sphincter muscles for days or even weeks than the sensation of poop coming out.

In the end, if your children have a sensory aversion to pooping, it doesn't really matter why they have it — what I've come to learn is that it's important to accept that they do and it's very real to them.

For some children, pooping is tolerable in some situations but not others. For instance, many kids (and mammals in general!) crave privacy and solitude when pooping, even if they're otherwise social creatures. It all has to do with sphincter law.

Plus, many children will accept pooping in a diaper or pants but not relish the sensation of the drop of poop into a toilet. They might also be afraid of balancing on a toilet, the loud flush, or bad experiences they've had with either. (I fell into a toilet when I was four and was stuck for awhile; true story.) This was not actually our experience with Mikko, but it's a common enough one that I will address it later.

Children might also have had a bad memory associated with pooping. When Mikko was a toddler and first started solid foods, he began solid poops for the first time as well — and he actually bled a little bit occasionally for the first several months. We felt awful, but it just seemed to be his body's opening getting used to bigger and badder poops, and we had to wait it out. His potty strike started soon after this and was likely related, and we wondered if his residual fear of pooping continued on from this.

I hate to say this, too, but you'll want to rule out the possibility of any sexual or physical abuse, which can manifest in elimination issues for young children.

For the purposes of this article, I'm going to assume that (a) you've thoroughly ruled out any physical problems and (b) you've determined your child is practicing stool withholding for sensory reasons.

What helps — and what doesn't

Be patient and understanding. Here's a newsflash: Berating them doesn't make them want to poop. No, seriously, I needed that newsflash. Sam and I would take it in turns to get so frustrated with the years and years it's been (so far) of pooping problems that we would want to just make Mikko poop. But it's obviously not the way to go. As the parent of a six-year-old who is getting better, I will give you this message of (mitigated?) hope: Things will change. It might take years, but your child will learn to poop. Even if poop aversion continues into adulthood, your child will have figured out a way through it. It just takes time. (Be patient with yourself, too: Take it from me — I know how frustrating and icky poop problems can be. It's all right to feel what you feel.)

Talk about it. Read children's books. (I have some recommendations below.) Talk to your child about your own poop habits and sensations. Point out when you notice your child is exhibiting signs of needing to poop, and talk about what that feeling is like. Keep it nonjudgmental and factual. Ask your child what it is about pooping that's so distasteful — does it hurt, or does it feel weird, or is it scary, or what? Kids might have trouble answering precisely, but it might help you at least weed out the things that aren't a problem. (For instance, we learned it doesn't cause pain for Mikko; he just doesn't like the feel.)

Insist on trying, but not on pooping. It's like your mom's favorite phrase before a car trip: Everyone has to go try. Don't make it a punishment; just make it a habit. It can be a regular thing (every night before bed, or after a meal, or whatever routine works for you guys), or it can be when you see your child clenching, but make a deal that your child will sit on the toilet and try to go. With Mikko, we set a time limit, and he'll negotiate us down. It's never more than ten minutes, and is sometimes as few as three. Don't express (try not to) frustration or disappointment if no poop is achieved; simply try again the next day. A good portion of the time now, Mikko's trying will translate into going, and we'll be done with it again for the next few days. Speaking of which:

Acknowledge that every body is different. I personally poop multiple times a day. (You totally wanted to know that, didn't you?) Sam poops every few days, I think. (He totally wanted you to know that.) Mikko seems to need to poop every few days as well. Even if you're a daily pooper, your child might not be, and that's all right, assuming there are no constipation issues. (Again, check with a medical care provider if you have concerns.) Trying to force Mikko to poop as often as I do would do neither of us any good.

Let the reward be intrinsic. I've read some books that suggest rewards like stickers for pooping, so you can give it a try if that floats your boat. For us, we wanted the relief of pooping to be its own reward. When Mikko has finished his pooping session, he gets a big grin on his face and comes over to give me a high five. We've talked a lot with him about how not-pooping limits his ability to play and have fun. We discuss that the feeling of pooping, however uncomfortable it makes him, is fleeting, and point out that afterward, it feels so good and light to be poop-free. Mikko naturally becomes ebullient after a poop, which makes it unfortunate that he very nearly always poops at bedtime….

Figure out the underwear situation. Part of my frustration with the poop-withholding was what it was doing to my laundry pile. Eventually, Sam and I came up with a couple unorthodox methods that helped ease everyone's tension levels.

First of all, I picked up a packet of big-boy disposable diapers, the kind older kids wear if they have a problem with bed-wetting. I was really, really resistant to buying these, and when Mikko first put on a pair, I even felt some revulsion … until I looked at his face. He was totally proud of how snazzy they looked and didn't feel in the least embarrassed to be wearing them. And … for the first time in awhile, he had no fear at all about getting poop in his pants. He knew from experience that I got annoyed when I saw another pair of undies ruined, and had even taken to hiding poop-stained underpants somewhere I wouldn't see them right away. (A sweet surprise for a future date: dried-up poo pants! Whee!) Wearing diapers again when he had to poop gave him the freedom to unclench a bit — literally. It also made him more fastidious about hygiene because he was now inclined to tell us his pants needed changing instead of furtively hiding the fact.

However, these diapers are pricey and disposable (i.e., wasteful), so Sam ended up combining this with another tactic: having Mikko pay for diapers or new underpants out of his allowance. I was a little hesitant about this, but the way Sam and Mikko set it up, it's turned out to be a really positive thing. First of all, it's totally not punishment-based; it's just reality. If all your underwear have poop in them, we need to throw them out, and you need to buy new underwear. This went along with Sam's merciless throwing away of poo-encrusted undies; I'd always tried to salvage and wash them, but I had to admit it was a pointless battle. One time, I had to wash a load three times to get out the smell, which is wasteful in itself. Anyway, this policy was very matter of fact: Mikko can choose to get poop in his underwear; he can choose to buy and wear diapers; he can choose to keep his underwear clean by pooping (or clean enough by pooping sooner). There are no accusations, and no more hidden undies. It has actually taken all the pressure off, because (a) we don't get mad that all his underpants are getting ruined, and (b) Mikko doesn't get nervous that we're going to get mad. Win-win.

What if kids will poop only in a diaper? This is a common scenario among kids who are poop resistant. Again, this did not actually happen for us — Mikko kept it in just as well in a diaper as not, but maybe his older age has something to do with that. I've heard of kids who will only poop in a corner, or behind furniture, squatting down, behind a plant, in their pants, or in a diaper. If your child will poop only in private, try gradually moving the private place to the bathroom, even if it's still in a diaper. If your child will poop only in a diaper, one suggestion I've read about a few times is to transition gradually from diaper to toilet by first having your child poop in a diaper but sitting on the open toilet seat. Then, cut a small poop hole in the diaper. Over a period of several days to weeks, cut a larger poop hole until the child is pooping through the diaper into the toilet. Some children, particularly if they're startled by sensory input, don't like the noise or surprise of a log splashing in the toilet, or maybe even just the feel of it stretching out of them into the abyss. We never tried this solution, because Mikko (at 5) didn't want to poop in his diapers, but it seems like a reasonable and compassionate one if done gradually, without blaming, and with the option to revert if the child feels uncomfortable at any stage. (My one reservation: How do you know where to cut the hole?? I guess look for the poo smear?)

Make the pooping situation comfortable. If kids are afraid of the toilet (which also applies perhaps to a reluctance to transition out of diapers), you might need to suck it up and use a little potty for awhile, even though I realize it gives you one more thing to clean. Even if a kid's older and is reverting to being untoileted, you could offer the potty as an option; its familiarity might keep you from no-poo-nightmares. You could offer other solutions as well: perhaps squatting over a cloth prefold, or squatting in the bathtub over a receptacle. Putting a seat reducer, a step stool, and even a handrail onto the big toilet can help a child feel more secure. For public toilets, hold your hand or place a sticky note or other barrier (diaper, wipe, flap of toilet paper) over the auto-flush sensor until your child can get up and away and cover ears.

As for giving kids privacy, that's worth mentioning here as well. Mikko is not by nature a private person. He will cheerfully barge in on me when I'm trying to poop. But for the past year or so, he's needed his own space and to be left alone when he's pushing, and we honor that need.

Also, if your child is having problems pushing and your child's legs are long enough, I'd also recommend a Squatty Potty or some other way of squatting while pooping (little baby potties are actually a pretty decent position for older kids). You might also be able to get some kids (not mine) to use a bidet (which we have and love), because it makes the wiping of constantly withheld poo not quite so onerous. (My kiddo's not so down with the random sensory input, as mentioned, to appreciate a cold spray on the bum, but it's a good option if your child will allow it.)

Nutritional support will help but probably not cure. It's not a bad idea to emphasize non-constipating foods and limit the constipating ones and offer your child a lot of natural fibers (vegetables and most fruits). Make sure your child gets plenty of liquids. Avoid foods your child has an intolerance to. You can offer daily probiotics to support gut health. It's wise to do what you can to keep stools soft and regular, since a hard and painful stool can set matters back even further. However, if your child's not constipated and is poop withholding, there's likely something else at play, and even the best nutrition won't work miracles.

Use medical interventions judiciously. A lot of people whose children struggle with pooping will at some point be recommended the use of fiber supplements, laxatives, stool softeners, or enemas. I'm not going to recommend what you should do for your specific situation, because see above re: I am not a doctor. I'll just tell you based on our own experiences:

First of all, stool softeners make sense if your kid has hard stools; ours does not.

Secondly, the stool softeners we could find for kids (i.e., not pills you have to swallow but something chewable or drinkable) were gross; the main kind we could find was fruit punch flavor that you were supposed to mix in with juice or — gag me — milk. Fruit punch milk? We're trying to make the kid poop, not vomit.

Thirdly, we tried laxatives, because we found some he could and would chew (though there was crying involved, because see above re: sensory issues and therefore he hates the taste of most anything medicine-y and absolutely everything new and unusual), but he can clench through laxatives. That's right — laxatives are entirely useless for a kid with a sphincter of steel, so I'd skip 'em if you can. They might have a little bit of psychological effectiveness because you can talk up that they make it easier for you to poo, honey, and you could suggest that your child will need to poop and then hope that's actually true.

Fourthly, enemas seem too rape-y to Sam and me unless our kid actually wants one. I say that with no judgment on anyone whose kid has medically required an unwanted enema or suppository; I'm just saying we did actually buy a box once when Mikko said he was up for it, but we've never used it, because he always backed down when push came to shove (ha — oh, I can't find any good language to talk about this issue; sorry).

If your child's poop withholding leads to medical problems, though, medical solutions might be the best call. Children with severely impacted stools, for instance, might need manual or even surgical removal. Again: me = not a doctor. So use your own parent sense and the guidance of medical professionals.

Things get better

I will say this again: It might be worse for a long, long time, but your child will learn how to poop. Without cajoling, without coaching, without threats or bribes or tantrums (yours or your child's).

With understanding, love, patience, and a good dose of common sense, you will all get through this, together.

Wishing you all good pooping!

Further reading

When researching this topic, I came across some children's books and articles that address the phenomenon of never-poopers. Some of these are directly related to sensory issues, and some more broadly encompass a range of physical and sensory obstacles to pooping. I'm not necessarily whole-cloth recommending them as just telling you: There's not a lot out there when looking for children's no-poop books, so you take what works and adapt what doesn't!

And, for some reason, we've appreciated this Australian video about Tom's Triumph, because it talks graphically (not joking) and vividly about the rumbling and smells that forewarn the need to poo:

Again, I'm not claiming the above resources are the perfect fit (for instance, the first one was on target, topic-wise, but a bit too rewards-based for our family), but they're good for sparking a low-key and positive conversation about pooping and taking some of the fear out of the process. You might check to see which of the books your library has available.

Do you have a child who WILL NOT POOP? What has worked for you? What has not worked at all?

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comments:

I know a preschooler who has sensory issues relating to the smell of poop. So he would only poop in pull-ups. But now will poop on a potty seat if (but only if) a big air filtration device is placed right next to it and turned on to "turn the stinky poop air into fresh air"!Hopefully the air filtration device and the pooping can both move to the bathroom soon...we'll see!!

My sensory dude thankfully doesn't have this problem, but he didn't even *start* pottytraining until he was 3.5 and he was almost four when he finally started pooping on the potty. Before that, he would put on his own pull-up and poop in it. Once a day. He'd crouch behind the couch and do his business.

How do you know when your kid is old enough to potty train? When they can take off their own pants, put on a pull-up, put their pants back on, maneuver behind the couch ... you get the idea.

I tried mightily not to pressure him to use the toilet for pooping because several of my friends' kids suffered from poop withholding issues. ARGH. But I seriously wondered if Joe would be wearing diapers into high school. Seriously!!

This is not an easy subject to talk about, and I appreciate your honesty. I have spent a lot of time in a potty-learning spiral of "WHAT DID I DO WRONG??!!!"

But like you say, they usually do figure it out eventually. I remember I hated the school bathroom so I would hold it all day and by the time I got home, I'd be suffering from excruciating cramps. :( Mikko, baby, that is NOT a good feeling!!!

One more thought - we enjoyed watching the Dinosaur Train episode about how "Everyone Poops." All of the dinosaurs poop, and the little dinosaurs are reminded to listen to their bodies and go when they need to. There's a catchy song and everything! :-)

Great post! I am a psychologist who specializes in working with parents and young children, but that sure hasn't exempted me from struggling with different issues with my own kids. My youngest has struggled in a very similar way to Mikko, and we have used a trial-and-error approach similar to yours. Your wonderfully honest story of how you've managed these toileting issues is so helpful because it proves the only "one-size-fits-all" advice for parenting: there IS NO one-size-fits-all approach. I'm going to bookmark your blog and recommend it to families I work with. Thank you!

Please, please, please leave this blog post up! It has been a life saver for my 4.5 year old girl (classic withholder). With in one week of buying her a reward and then putting it up she has pooped in potty 3 times without prompting!!! I'm hysterical I'm soooooo excited at her progress. This from a girl who says poop belongs in her and not out of her! From a girl who lets the poop go in and out of her butt all day long without going that I have to wipe her skid marks 3-6 times a day. From the girl who struggles with diaper rash almost every day!!! I see the light!!! Thank you so much for helping my family!!

I came across this post after hearing from a grandparent who is concerned about their grandchild being unwilling to poop in certain places (her house, etc.) I was looking for a direction in which to go to advise her and also speak with the child (I am a School Counselor). Thank you for this post...it is thorough and helpful!

My 4.5 year old refuses to let herbpoop come out!! She screams and cries (weeks at times) and will only "go" in a pull up and needs to completely hidin from everyone! She acts like it hurts, and really have no clue why she started doing this clenching, she used to jist go hide and let it out and about a year ago, she started holding it in like her life depended on it! I'm thinking now that she just don't like the feeling of it coming out! I've done everything and still trying to get her to just please let it out, cuz once she does let some come out she's just fine, and will finally sit, play, and live life, but when she holds it in our family life is on hold cuz she will NOT sit, she will NOT eat, she won't do anything! I need any help I can at this point! School is right around the corner for her so we need to nip this in the butt, no pun intended! Sincerely A desperate mother Ericka

@Ericka MisamoreGreat article! To Ericka, my 4.5 year old son just started doing this after an episode of constipation, which we got through, then the next day his dad and I took our first trip together since his birth and he wouldn't poop while we were gone, but finally did the night before our return 5 days later! Since then, running around the house screaming trying to hold it in, won't sit, won't go. His only desire is to lay down (as that seems to help him hold it in). So everything for the last month revolves around the bed(s) or the couch. Chairs are a problem. In the beginning, we let him eat meals on the couch, as we thought it was constipation again, but now that's the only place he wants to eat any meal. Leaving the house or going anywhere is a pain as he just wants to go home as his backside "hurts". Says he "feels better" after going and admits that it doesn't hurt, but we won't go unless he just can't hold it in anymore! He was going daily in a pull-up until a month ago, and we were ok with him taking his time to be ok with the potty. Thought school would help this as other kids at pre-school poop, although a teacher at the school said about 40% don't.

I'm frustrated, and the last episode at a restaurant had him with a pull-up on, screaming at the top of his lungs and hitting me as he bounced between the two walls of the stall - although back at the table, he was sweet as pie (his usual self) and wanted his parents sitting right next to him.

I've tried incentives, bribes, calm encouragement, frustration, and reason. In reading this article, maybe we're in for a long haul, and I'm just at a loss feeling uncertain without answers. I'm afraid that what I'm doing may be making it worse! Help!

My 3.5yo has been a dream to potty train, she has been since shortly after she turned 2. But for the last almost year, it's been refusal to poop. I am so tired of the struggle! I don't put any pressure or stress on the need to poop, after doing my Google research when it started. So all my frustration is staying inward and that in itself is difficult. We've got between diapers and underpants and no success with either. Just an absolute refusal. She says it hurts to hold it, hurts to push it. She just doesn't want to poop ever again. She's gone twice in the last month! The doctor is not concerned at all. It's not constipation, either. I've began wondering, since I believe it's a control issue, if we need to see a child counselor. I'm just struggling right now!

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Riding the rails with my husband, Crackerdog Sam, and our hobo kids, Mikko Lint Picker (born June 2007), Alrik Irontrousers (born May 2011), and Karsten (born October 2014). Trying every day to parent intentionally and with grace.